Healthcare Provider Details

I. General information

NPI: 1568376754
Provider Name (Legal Business Name): MATTHEW MORTENSEN
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2026
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 SOUTH ST
CHARDON OH
44024-1499
US

IV. Provider business mailing address

7106 BARTON DR
MENTOR OH
44060-4409
US

V. Phone/Fax

Practice location:
  • Phone: 440-251-2406
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberS-2614681
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: